Provider Demographics
NPI:1730132374
Name:IOSILEVICH, MIRON A (MD)
Entity Type:Individual
Prefix:
First Name:MIRON
Middle Name:A
Last Name:IOSILEVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 JAMES ST
Mailing Address - Street 2:MENTAL HEALTH SERVICES
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203
Mailing Address - Country:US
Mailing Address - Phone:315-703-2700
Mailing Address - Fax:315-703-2730
Practice Address - Street 1:742 JAMES ST
Practice Address - Street 2:MENTAL HEALTH SERVICES
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203
Practice Address - Country:US
Practice Address - Phone:315-703-2700
Practice Address - Fax:315-703-2730
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17274512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01125800Medicaid
NY01125800Medicaid
B83025Medicare UPIN